A historical perspective and evolution of our knowledge on the cardinal ligament

Neurourol Urodyn. 2014 Apr;33(4):380-6. doi: 10.1002/nau.22421. Epub 2013 Jun 10.


Aims: The objective of our review is to provide a critical appraisal of the literature on the anatomy, structure and roles of cardinal ligaments (CL) in pelvic organ support, in conjunction with the currently evolving evidence based mainly on imaging and biomechanical modeling studies. We aim to contribute to the understanding of the pathophysiology of pelvic organ prolapse (POP) and stimulate new insights in research and development of novel surgical approaches for POP.

Methods: PubMed, Embase, Scopus-Elsevier, and Cochrane Databases were searched in English and German. Studies from 1870 to 2012 were identified. The keywords used were "cardinal ligament," "transverse cervical ligament," "Mackenrodt ligament," "parametrium," and "paracervix." Cross check and Google search of the reference lists were used for missing articles.

Results: We identified 35 related articles. Located at the base of the broad ligament, the CL is a supportive structure that attaches the cervix and upper vagina to the pelvic wall. The ligament contains the uterine vessels and hypogastric plexus. It conducts most of the pelvic loading forces. On MRI, it appears as a web-like structure around the axis of the internal iliac vessels. Their clinical importance is based on the apical supportive role and lymphatic-rich structure, involved in dissemination of cervical cancer.

Conclusions: The structure and role of the CL have been long studied, but remained unclear. Recent studies on imaging and biomechanics have improved our understanding and provide new insights which may enable the development of new techniques in prolapse surgery.

Keywords: anatomy; cardinal ligament; pelvic connective tissue.

Publication types

  • Historical Article

MeSH terms

  • Cervix Uteri / anatomy & histology*
  • Cervix Uteri / blood supply
  • Cervix Uteri / innervation
  • Cervix Uteri / physiology
  • Cervix Uteri / surgery
  • Female
  • Gynecologic Surgical Procedures
  • History, 19th Century
  • History, 20th Century
  • History, 21st Century
  • Humans
  • Ligaments / anatomy & histology*
  • Ligaments / blood supply
  • Ligaments / physiology
  • Urology / history*